Select Committee on Health Written Evidence

Evidence submitted by Adam Beckman, Plymouth Hospitals NHS Trust (AUDIO 38)

  I am the Head of Audiology Services for Plymouth Hospitals NHS Trust, where I have been for just under two years. Prior to this, I was the Team Leader for Adult Rehabilitation/Hearing Aid Services at the Royal National Throat, Nose and Ear Hospital, and a lecturer at the Institute of Laryngology and Otology (a post-graduate institute of University College, London). I therefore have personal experience of leading hearing aid services in two highly different services, and have a high level of theoretical expertise.

  I was also seconded to the RNID as the Project Audiologist for the Modernising Hearing Aid Services Programme. This gave me an incredibly broad perspective of audiology services across England.

  Since moving to Plymouth, I have been responsible for developing the service to manage the huge waiting lists that had developed. Now that funding has been approved by the PCTs, we are in the process of clearing these, and are on target to see all 6,000 patients with waits of greater than 13 weeks by 31 March 2007. This is being achieved with a combination of NHS provision and short-term private sector partnership.


    —  The reasons for the large numbers of patients waiting excessive lengths are complex, but are largely a result of under-staffing for a long time.

    —  I believe that there could be sufficient capacity within the system to provide the services required within a sensible timeframe.

    —  However, I have grave concerns for the adequate treatment of our patients with the current round of independent sector commissioned work which is due to come on stream in April 2007, and fear that it will have a negative impact on NHS Audiology services.


  1.  I believe that accurate waiting time data for Audiology services can be available. However, due to the variety of systems used to manage waiting lists, the accuracy of data is reliant on high level support from Trust performance information teams, which may not always have been made available. Thus, current data may not be wholly reliable.

  There is an additional confounding factor. For most basic diagnostic testing provided by Audiology services, there is a zero waiting time. However, this activity—direct support to ENT services—is not typically counted.

  2.  Audiology services appear to lag behind many other services in terms of waiting times for many and complex reasons. However, I believe that the key reasons can be summarised as follows:

 (a)   Failure to invest in the workforce long-term

  Many Audiology services have had too few staff for many, many years. They have been able to keep going through a combination of hard work, recurrent "waiting list initiatives" and, frankly, very poor quality working practices. When higher quality, evidence-based practices were introduced, there was insufficient capacity in the system to manage this.

 (b)   Impact of waiting time targets for ENT services

  Consecutive efforts, year on year, successfully reduced waiting times for ENT services. However, to do this, additional ENT outpatient clinics were required. These needed Audiology support, taking staff away from hearing aid services that were already stretched.

 (c)   Impact of changes to community audiology services

  In many areas, clinical medical officers used to run paediatric community Audiology services. It has generally been recognised that this was inappropriate, and the services now typically come under Audiology. However, there were often no additional Audiologists made explicitly available in workforce planning to take on this work.

 (d)   Impact of the introduction of digital hearing aids and evidence-based protocols

  The huge investment that has been made to improve the quality of hearing aid services for patients is wholeheartedly welcomed. The improvements in outcomes and quality of life are extraordinary. However, the changes created a huge surge in demand. As many services were stretched already, and as resources were actually being diverted away from hearing aid services to the "targeted" ENT services, this resulted in greatly increased waiting times.

 (e)   "Rapid" introduction of the 13 week waiting time targets

  Many of us involved in the Modernisation of Hearing Aid Services (MHAS) Programme could identify a pattern across services of a five year trajectory. It became evident that the surge in demand would take approximately that long to manage in most services. Those services which were among the first to join the programme (First Wave) have now returned to the steady state. Those which only started in later stages, such as 2004-05, are still in the process of managing this surge in demand whilst now having to contend with the 13 week targets.

  3.  In areas that have had investment over a long period, NHS Audiology services are clearly able to manage the demand. This is shown by the wide variation in waiting times (and numbers waiting) across England. Should the higher levels of funding available in some areas be made available to struggling services, along with the introduction of the proven methods for reducing queues and matching capacity and demand, I have no doubt that NHS Audiology services could meet the current demand.

  4.  It is not obvious that there is sufficient capacity to meet the "unmet need". Early intervention studies do suggest some advantages to this approach. However, it is not obvious that, in the current framework, seeking additional work should be the priority.

  5.  It is likely that enough Audiologists are being trained. However, there has been a failure of the DH and professional bodies to ensure the introduction of the Associate Practitioner to support services.

  6.  Having worked with the Public Private Partnership, with some success, I believe that there can be a role for the private sector in providing Audiology services. However, I have extremely grave concerns for the welfare of our patients in the current round of IS commissioning.

  7.  By grouping audiology with diagnostic services, it is apparent that the successful bidder, certainly in our region, does not have a clear understanding of what is meant by an audiology service. They are on a very steep learning curve, but as they are supposed to "go live" in less than two months, I fear that the quality of service that patients in our area will receive will be significantly compromised.

  8.  I am also concerned that the funded levels of activity for the IS are based on old data. Therefore, in areas where waiting lists are being successfully reduced now to help meet the 13 week waiting time targets, there is likely to be over-capacity in 2007-08.

  9.  As the IS provision comes from ring-fenced funding, I fear that commissioning decisions will result in resources being moved from NHS Audiology services, despite the best intentions of the DH. This would result in the individual and institutional expertise in managing our patients being lost or broken up.


    —  There is a need for "joined up planning" at the DH. The 13 week/18 week pathway work, which covers many specialties, is running ahead of the National Audiology Plan. It is essential that these strands are developed rationally, so that the NAP is not driven by the political need to reduce waiting times rather than ensuring that we have services that will most effectively meet the needs of our patients long-term.

    —  There must be rigorous and transparent Clinical Governance pathways with appropriately qualified specialists to ensure that the centrally managed IS providers are accountable as locally funded NHS providers are.

Adam Beckman

Head of Audiology, Plymouth Hospitals NHS Trust

8 February 2007

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